Gastroenterologist and surgeon perceptions of recommendations for optimal endoscopic localization of colorectal neoplasms

National consensus recommendations have recently been developed to standardize colorectal tumour localization and documentation during colonoscopy. In this qualitative semi-structured interview study, we identified and contrast the perceived barriers and facilitators to using these new recommendations according to gastroenterologists and surgeons in a large central Canadian city. Interviews were analyzed according to the Consolidated Framework for Implementation Research (CFIR) through directed content analysis. Solutions were categorized using the Expert Recommendations for Implementing Change (ERIC) framework. Eleven gastroenterologists and ten surgeons participated. Both specialty groups felt that the new recommendations were clearly written, adequately addressed current care practice tensions, and offered a relative advantage versus existing practices. The new recommendations appeared appropriately complex, applicable to most participants, and could be trialed and adapted prior to full implementation. Major barriers included a lack of relevant external or internal organizational incentives, non-existing formal feedback processes, and a lack of individual familiarity with the evidence behind some recommendations. With application of the ERIC framework, common barriers could be addressed through accessing new funding, altering incentive structures, changing record systems, educational interventions, identifying champions, promoting adaptability, and employing audit/feedback processes. Future research is needed to test strategies for feasibility and effectiveness.

the five CFIR domains aligned with the study objectives.Detailed rationale for which constructs were included are reported in Additional file 2.
Interviews were conducted by video teleconference (Zoom Video Communications, San José, CA), according to local COVID-19 pandemic-related restrictions.Participants were provided with a copy of the recommendations both prior to and at the beginning of the meeting.A previously published visual infographic tool was used to help participants understand and refer to the recommendations 5 .All interviews were audio-recorded and later transcribed by the primary analyst.

Data analysis
Units of analysis Data were categorized according to the CFIR constructs separately by provider specialty (i.e., gastroenterologist or surgeon).Within each group, constructs were subsequently categorized as facilitators or barriers according to coded perceptions.Findings from the two groups were then compared using a triangulation process to identify common and contrasting themes between specialties.

Data coding
Interview transcripts were imported into NVivo software for Mac (version 12.2.0;QSR International, Melbourne, Australia) for analysis.Coding was performed in duplicate independently by two researchers (GJ and CEK) using directed content analysis 30 .This deductive qualitative research approach is best used when an existing theory has previously been established to explain an observed phenomenon 30 , and has been used previously for analysis of qualitative interviews using the CFIR 31 .Following this approach, transcripts were coded using a predetermined codebook and inclusion criteria (Additional file 3) 13 .
Each transcript was first analyzed at the entire transcript level; these were reviewed repeatedly and coded deductively to CFIR constructs according to the codebook.Data were then reviewed at the level of each interview question to check for additional information that was missed during initial coding.After the entire coding process, both analysts met and created a single unifying codebook through consensus.

Construct relative priority
After interview transcripts were coded, participant perspectives were ranked according to whether a CFIR construct was perceived as a barrier or facilitator to implementing the new recommendations.Ranking criteria were adapted from previous work, and which have been used previously to differentiate high from low-performance implementation settings 32,33 .Ratings were performed separately by both analysts.Ranking criteria were based on level of agreement among study participants' expressed views, language strength, and concrete examples used to emphasize responses (Additional file 4).

Validation strategies
Multiple strategies were used throughout the research process to ensure results' validity including triangulation, reporting disconfirming evidence, dialogic engagement, and reflexivity 34 .Validation strategy details are listed in Additional file 5.

CFIR-ERIC intervention mapping
Researchers have recently developed and refined a tool to align CFIR constructs to the expert recommendations for implementing change (ERIC) framework 20,22 .Barriers identified in a study setting can be entered into the tool's algorithm according to the CFIR framework, and subsequently the tool reports a prioritized list of strategies to consider, based upon prior consensus research 20,22 .The tool also reports the degree of consensus among the experts for each ERIC strategy as a method to address a particular CFIR barrier.According to this framework, strategies that were endorsed by ≥ 50% of the experts are deemed 'Level 1' strategies, and strategies that are endorsed by 20-49.9% of the experts are deemed 'Level 2' strategies [19][20][21][22] .The CFIR-ERIC authors suggest selecting a combination of both broadly applicable strategies, with high cumulative endorsement across multiple barrier constructs, in addition to specific strategies (i.e., level 1 strategy applicable to only one barrier) 22 .To ensure both approaches were addressed in this research, ERIC strategies were identified based on level 1 endorsement for each individual CFIR barrier, in addition to identifying more "general" strategies with high cumulative endorsement across all barrier constructs.ERIC strategies were stratified according to provider specialty.
Participants frequently proposed their own solutions during the interviews.In post-hoc analysis, these opinions were deductively coded to the ERIC framework and compared to those strategies identified via the CFIR-ERIC tool.

Research team and reflexivity
The interviewer and primary analyst (GJ) was a male general surgery resident and master's in science student throughout this research process.He was previously acquainted with many of the research participants prior to the interviews through his residency training.All attempts were made during the research to minimize the effect of biases these relationships may cause by acknowledging them throughout the research, discussing emerging findings with the research team, and critically examining the effects on the knowledge generated at each interview and during analysis.

Conference presentation
Partial results from this work were presented as a poster at Digestive Diseases Week 2022 in San Diego, CA and at the Canadian Surgery Forum 2022 in Toronto, ON, Canada.

Participant demographics
There were 33 surgeons and 19 gastroenterologists who treat colorectal cancers identified as potential participants in Winnipeg during the study period.Of the 52 individuals invited, 11 gastroenterologists and 10 general surgeons participated in the study between October 2021 and January 2022.Participant demographics are shown in Table 1.Individuals participated from every endoscopy suite, hospital, and operating room in the city.Mean interview time was 56 min and 55 s.

CFIR content analysis
Twenty-seven CFIR constructs were assessed and deemed relevant to the research questions.Perceived barriers and facilitators to following the new recommendations are summarized according to construct relative priority rankings in Table 2.
Both major (n = 4) and total facilitators (n = 11) were more numerous for surgeons compared to gastroenterologists (9 total, 2 major).Gastroenterologists and surgeons had eight net facilitator constructs in common: 'relative advantage' (major for surgeons only), 'adaptability' , 'trialability' (major), 'complexity' (major for surgeons only), 'design quality and packaging' , 'cosmopolitanism (major for gastroenterologists only)' , 'structural characteristics' (major for surgeons only), and 'tension for change' .Uniquely, surgeons identified 'innovation source' , 'self-efficacy' and 'leaning climate' as facilitators, whereas gastroenterologists highlighted 'leadership engagement' .The only universally acknowledged (major) facilitator for both groups was the ability of the recommendations to be trialed prior to full implementation.Surgeons identified ten barriers whereas gastroenterologists identified nine.All nine gastroenterologist barriers were also identified as barriers for surgeons: 'external policy and incentives (major)' , 'organizational incentives and rewards (major)' , 'available resources (major)' , 'goals & feedback' (major for gastroenterologists only), 'access to knowledge & information' , 'knowledge & beliefs about the intervention' , 'self-efficacy' , 'individual identification with the organization' , 'evidence strength and quality' , and 'costs' .The tenth barrier for surgeons, 'compatibility' , had more mixed perspectives for gastroenterologists.Table 3 provides a summary of barriers and facilitators identified within each construct with exemplar quotations according to gastroenterologists and surgeons.

CFIR-ERIC strategy matching
According to the CFIR-ERIC matching tool, strategies to address barriers identified by gastroenterologists and surgeons are displayed in Figs. 1 and 2, respectively.The top four ERIC strategies were identical for both gastroenterologists and surgeons: 1. 'Conduct educational meetings' , 2. ' Alter incentive/allowance structures' , 3. 'Identify and prepare champions' , and 4. ' Access new funding' .The CFIR-ERIC tool also identified six level 1 strategies (indicated in bold in the figures) to address CFIR barriers.Again, these strategies were identical for both gastroenterologists and surgeons: 1. 'Conduct educational meetings'; 2. ' Alter incentive/allowance structures'; 3. ' Access new funding'; 4. 'Develop educational materials'; 5. ' Audit and provide feedback'; and 6. 'Distribute educational materials' .Table 2. CFIR rankings stratified by participant specialty.− 2 = "major" barriers, universally recognized as barriers by all participants with specific illustrative examples; − 1 = minor barriers, mixed opinions with overall barrier effect; '0' = mixed perceptions; + 1 = minor facilitator, mixed opinions with overall enabling effect; + 2 = major facilitator, universally recognized as a facilitator by all participants, with specific illustrative examples.Significant values are given in bold.Fee-for-service reinforces repeat endoscopy (Barrier)

Gastroenterology Surgery
"If we're paid for per scope right, then there's an incentive to be able to re-scope" (Surgeon 3) "Repeat procedures result in payment for surgeons".(Gastroenterologist 4) Inner setting

Structural characteristics
Staff turnover prevents sustained QI (Gastroenterologists only; barrier) "The nurses turnover, managers turnover, just the culture doesn't change" (Gastroenterologist 5) Small, well integrated community with central organization (Facilitator) "We have a nice relationship now, and not an antagonistic relationship that we had 15 to 20 years ago between surgeons and gastroenterologists. " (Gastroenterologist 8) "We're organized to some degree through central intake, even though it's mostly a booking system.Which allows for dissemination of information and application of standards" (Gastroenterologist 11) "Winnipeg's a small enough place, everybody goes, 'Yeah, okay.You know, the next guy is doing it, the guy down the street is doing it.I know them both.I'll do it.'" (Surgeon 14)

Networks and communications
Some past endoscopy initiatives were poorly communicated.(Barrier) "Some things just come out of nowhere.We started doing endoscopic timeouts recently, similar to surgical timeouts.People just started doing that one day without ever talking to anyone.This sounds great.I think this is important.There's lots of research literature, but I didn't realise we were starting this here." (Gastroenterologist 2) "Some of it is just this random, somebody somewhere sends an email and I look at it go, OK, we're doing this now, right" (Surgeon 3) Poor engagement with virtual rounds (Surgeon only; barrier) "My sense is that a lot of people log into these round sessions and perhaps check their emails and do whatever else on their phone in the virtual format."(Surgeon 7) Performance feedback is rare between providers (Barrier) "We don't really get feedback unless it's from the surgeon that we refer to."The ongoing COVID era and human resource crisis in the health care system probably values efficiency more than QI innovation.I think the way I would pitch that as a sales tactic is that minimizing repeat endoscopy is efficiency" (Surgeon 7)

Organizational incentives
No relevant organizational incentives identified (Barrier) "There's no penalties if you don't follow it" (Gastroenterologist 8) "I don't think there's any incentive other than just to the patient," (Surgeon 1)

Goals and feedback
No formal relevant feedback processes (Barrier) "There are some provincial audits, but we never hear about them" (Gastroenterologist

Participant suggestions for implementation
Participants had many suggestions for how they would like to see the new recommendations implemented in their setting.Of the 73 total ERIC constructs, 24 were addressed by at least one participant during the interviews.The number of participants who endorsed a specific ERIC strategy are listed, and compared to percent endorsement according to the CFIR-ERIC strategy tool output in Table 4.The top five participant recommended strategies were: 1. ' Audit and provide feedback' , "The best way probably would be for someone to have some degree of formalized feedback on their performance, which probably means receiving feedback on some scheduled time interval rather than feedback regarding each individual case." (Surgeon 7); 2. 'Change record systems' , "The only other debatable thing which I don't see it happening would be if somehow in EndoVault you actually recorded the endoscopies," (Gastroenterologist 18); 3. 'Distribute educational materials' , "Place the infographic by the computer to reference during your paperwork." (Gastroenterologist 18); 4. 'Conduct educational meetings' , "A five-minute ad right before the next surgery or the next journal club or a five-minute plug before the next the GI Journal Club, right?Those are forums where you're getting enough people coming that you're going to get critical mass." (Surgeon 14). 5. 'Promote adaptability': "Change anything that they perceive as an extra step".

Discussion
Various groups have created recommendations to standardize lesion localization techniques 9,[35][36][37] , however, there is large variation in these practices 25,27,38,39 .New Canadian Delphi consensus recommendations for optimal endoscopic localization of colorectal neoplasms provides a framework to standardize practices between providers 5 .Guided by the CFIR, the present research identifies across gastroenterologists and surgeons in a major Canadian city: (1) consensus on barriers and facilitators to implementing these new recommendations, and (2) areas with mixed perceptions both within and across study groups.Importantly, most barriers (9 out of 10) identified were common to both gastroenterologists and surgeons.The CFIR-ERIC strategy-matching algorithm was used to propose externally validated (based upon expert consensus) types of strategies needed to overcome perceived barriers.Study participants also proposed their own implementation strategies.Due to similarities in perceived barriers between specialty groups, top ERIC strategies were identical for both specialties.There was also substantial overlap between expert-recommended strategies, and those suggested by our participants.Combining these approaches allows us to narrow down from a list of 73 ERIC categories into seven context-specific implementation strategies, including: 1. ' Access new funding' , 2. ' Altering incentives/allowance structures' , 3. 'Change record systems' , 4. Educational interventions (i.e., ERIC recommends: 'Distribute educational materials' , 'Develop educational materials' and 'Conduct educational meetings'), 5. ' Audit and provide feedback' , 6. 'Identify and prepare champions' , and 7. 'Promote adaptability' , The first three strategies in particular address the most common 'major' barriers identified by both specialty groups, which stem from a lack of internal and external organizational factors to incentivize compliance with the recommendations, and a lack of key resources needed to follow the recommended practices.
While one strength of the CFIR-ERIC framework is its flexibility, its breadth also makes these recommended strategies relatively non-specific.How these strategies can be utilized in future implementation efforts depends upon budget constraints, logistical considerations, and knowledge translation expert interpretation.Our participants' suggestions allow us to tailor these recommended strategies into more prescriptive "next-steps,"  recognizing that multiple interventions are possible, and these strategies need to be evaluated prospectively to ensure their validity.One major barrier identified by both gastroenterologists and surgeons was a lack of specific resources required to follow the new recommendations.Therefore, 'accessing new funding' , recommended by ERIC, is likely essential to any proposed solution.For example, new funding could be used to apply for resources such as modifications to the endoscopy medical record system or increase access to recommended materials (e.g., magnetic endoscope positioning device).
A lack of incentives to encourage compliance with the new recommendations was also a major barrier identified.Altering incentives, (e.g., pay-for-performance) is one of the most frequently studied ERIC strategies and is the subject of two recent systematic reviews.Both reviews identified mixed or inconsistent effects of pay-for-performance, and it is unclear which types of incentives targeted at which individuals are likely to lead to improved care 40,41 .While altering incentives is an expert-recommended strategy 20 , others suggest that this strategy is best used in combination with others, as it is unlikely to help overcome systemic barriers that prevent guideline adoption 42 .Altering incentive/allowance structures was also repeatedly mentioned as a desirable strategy by our participants.One popular suggestion was to provide additional compensation for a tattoo placed and documented exactly as recommended.
While not explicitly recommended according to the CFIR-ERIC strategy matching framework, 'change record systems' was a top strategy endorsed by our participants.Participants emphasized that local record systems do not allow for easy documentation of the recommended practices (e.g., tattoo information requires free text input).Furthermore, synoptic reporting has strong efficacy evidence for improved documentation of quality indicators in surgery 43,44 , diagnostic radiology 45 , and pathology 46 .Given the evidence of synoptic reports' efficacy, changing www.nature.com/scientificreports/medical records (i.e., implementing a purpose-specific synoptic report) represents an important strategy to consider locally, although would likely require additional financial resources to implement and maintain.'Educational interventions' are designed to disseminate knowledge about the new recommendations.Educational interventions have been independently associated with increased clinician adherence to guidelines on a recent systematic review and meta-analysis 47 .However, optimal methods of clinician education to encourage guideline compliance are unknown 48 .Example strategies proposed by our participants include informational emails, infographic posters in the endoscopy suites, and grand rounds presentations.Combining educational interventions with additional implementation strategies appears to be superior to educational interventions alone in some settings 49,50 .
' Audit and feedback' has strong empirical evidence to support its' effectiveness 20 , based upon a large Cochrane systematic review and meta-analysis 51 .Although the benefits of audit and feedback observed were generally small, and were highly dependent upon the method of feedback used and the baseline performance 51 .There are many potential aspects of the present recommendations to target for feedback.A common example raised by our participants was tattoo quality.Some endoscopists said they wouldn't raise a saline bleb, place a 3-quadrant tattoo, or that the volume of injected ink was unimportant.However, previously local surgeons have raised tattoo quality as a major issue for lesion localization 38 .Prospective evaluation and feedback on these and other recommended practices is one method to address these concerns and provide real-world local data to encourage providers to fall in line with the recommendations.
'Identify and prepare champions' was a top recommended strategy, primarily as it is the highest endorsed ERIC strategy to address cultural barriers in an organization.Participants also mentioned champions as individuals who could continue to spur uptake of the recommendations on an ongoing basis after the initial implementation measures are over.As with many ERIC strategies, the effectiveness of implementation champions to address culture barriers are based primarily on expert opinion, and there is a paucity of evidence to inform the validity of this approach 20 .
Finally, 'promote adaptability' is important, as it reflects the reality that it is currently unknown if every recommendation must be followed to enhance localization and diminish repeat endoscopies, or if instead some recommendations can be ignored, and the desired effect will still occur 5 .To address this concept, the CFIR introduces the concept of an intervention's "core components" versus its "adaptable periphery" 13 .The core components are the aspects of an intervention that must be followed for implementation success, whereas the adaptable components are the optional aspects that may not necessarily be required.The authors of the Delphi consensus recommendations suggest that recommendations with lower consensus could be considered "optional", whereas those with higher consensus (i.e., consensus from the first Delphi voting round) are more strongly recommended 5 .
Taking all of these recommendations together, a possible implementation strategy in Winnipeg might include: modification of the endoscopy synoptic reporting system to include items from the new recommendations; purchase of magnetic positioning devices for all endoscopy suites in the city; the provision of additional compensation for a tattoo placed and documented exactly as recommended; a multi-faceted educational intervention including informational emails, infographic posters in the endoscopy suites, and grand rounds presentations; implementation of a systematic audit and feedback strategy targeted at tattoo quality, and compliance with recommended documentation; recruitment of individuals at each endoscopy suite to champion implementation of the new recommendations and maintain enthusiasm; and an adaptation plan where recommendations with lower consensus can be modified while maintaining the "core" highly recommended aspects.

Contributions to the literature
To our knowledge, this is the first study in the literature to use the CFIR to examine barriers and enablers to implementing a new guideline targeted towards gastroenterologists and surgeons to reduce repeat endoscopy.Using this approach, we have applied modern implementation science methodology to identify strategies that may be used to enhance uptake of the recommendations in Winnipeg in the future.Others have attempted to evaluate endoscopy guideline implementation and quality improvement, however, those prior efforts are difficult to compare due to their lack of frameworks, and poor reporting of implementation strategies 25,38,52,53 .A strength of the current research is that by selecting robust, frequently used frameworks (CFIR and ERIC), we position the present research in the context of a broader body of literature 13,20 .This process has many benefits.For example, by following a structured theory-based framework, our research can serve as a sort of formula for others to follow suite.While our results are not necessarily applicable to implementation of the new recommendations outside of Winnipeg, the processes used are open to critique, and readily applicable elsewhere 54 .Our literature review also provides an up-to-date summary of the strengths and limitations of the CFIR and ERIC constructs evaluated.By using a framework, it is also imminently apparent to ourselves, and to other researchers, which aspects of the study setting have been evaluated, and which areas need further research (e.g., the entire 'process' domain, and the 'innovation source' and the 'stage of change' constructs).Had we used an inductive or tacit-knowledgederived framework, deficient areas may not have been as apparent 54 .
Another major benefit of using an implementation science framework is that we have built upon the previous advances of others 13 .For example, our CFIR construct ranking criteria has been used previously on a post-hoc basis to examine factors associated with prior implementation success for weight management 33 and hypertension strategies 32 .We built upon this prior research in multiple ways.First, we expanded up Damschroder and Lowery's construct ranking system 32,33 .We modified their system and adapted to the pre-implementation phase, which has never been done previously.We propose using this ranking system as a new way to identify barriers significant enough to warrant selection of ERIC strategies.Previously researchers have selected ERIC strategies according to all CFIR barriers identified by participants, without a method of determining their relative significance 22 .Others selected ERIC strategies for all CFIR constructs, regardless of whether they were perceived as a barrier or facilitator 55 .Furthermore, now that we have a baseline assessment, we could also evaluate how perceptions of CFIR constructs in Winnipeg change in response to implementation strategies for our new recommendations.
Another unique aspect of our research is that we have expanded implementation science frameworks to a new discipline: endoscopy guideline-implementation.Colon cancer screening has been previously evaluated using implementation science framework [56][57][58][59] , including the CFIR 60,61 , but to our knowledge, guidelines for implementation of new endoscopy practices have not been evaluated with any implementation science framework.
A final unique aspect of our research is we have identified a disconnect between what strategies our clinician participants desire compared to those that are recommended by experts.To our knowledge, this is the first study to specifically examine the differences between strategies endorsed by the CFIR-ERIC experts, and those strategies desired by research participants.The CFIR-ERIC strategies are purported to address CFIR barriers according to expert opinion, but as discussed above, to date there is little empirical evidence to support selection of one strategy over another 22 .Comparison between ERIC strategies, or to those strategies identified by research participants represents an interesting avenue for further research.These comparisons may provide much-needed evidence for how a strategy can be selected in the future.Presumably, participants would be more likely to buy-in to ERIC strategies they specifically endorsed, although there is no evidence to support this yet.

Limitations
Despite the important of our findings, this study design has some important limitations.First, the barriers and enablers identified are specific to the participants and settings evaluated, and should not be interpreted as broadly generalizable.This is not an inadequacy of the present research, rather, it is an inherent characteristic of qualitative descriptive research methodology 62 .Despite this limitation, the research processes used can be repeated in other settings to guide implementation elsewhere.Due to our use of CFIR, our findings may also be comparable to other settings.

Figure 2. (continued)
A second limitation is that after our study completion, a new version of the CFIR was developed to reflect ongoing developments in knowledge translation research 63 .While the new CFIR has some new concepts, our data could be mapped to the new CFIR if necessary, to allow comparisons in future research.
Another limitation is that alternate coding systems or frameworks could have been used.There are hundreds of knowledge translation frameworks described 54 .We selected the CFIR and ERIC frameworks due to their broad applicability, and good fit for the research questions, methods, and settings.However, another framework could have been selected and possibly led to different results.Even within the CFIR, there are multiple methods of analysis and data coding that are possible 64,65 .For example, neither the CFIR nor the ERIC framework define what constitutes a significant barrier that is important enough to warrant application of dedicated implementation strategies 13,20 .In our analysis, we selected "net" barriers as those in need of ERIC strategies, with specific emphasis on 'major' barriers.However, there is no compelling evidence to suggest that only these barriers require solutions.In the present research, even net facilitator constructs had some associated barriers.One strategy is to target ERIC strategies to all barriers identified, no matter how infrequent 22 .Another approach is to target ERIC strategies to overcome barriers and also to amplify facilitators 55 .Had we followed either of these alternate approaches, we would have identified nearly every CFIR construct as in need of an ERIC strategy, which defeats the purpose of examining local barriers and facilitators a priori to identify targeted strategies.
One final limitation was that our research reflects only the perspectives of surgeons and gastroenterologists who participated.While a significant portion of all gastroenterologists and surgeons in Winnipeg chose to engage in the study (21 out of 52 possible participants), and hailed from diverse practice settings and backgrounds, our findings may not reflect the perceptions of those who chose not to participate.Furthermore, nurses, patients, healthcare administrators, allied health professionals, non-physician policy makers, and managers were excluded.This was done deliberately, as the new recommendations are targeted primarily at physicians, and their perspectives were felt to be key for devising next steps in the implementation process.Now that local gastroenterologist and surgeon perceptions are known, these additional stakeholders should be engaged to ensure their perspectives are considered for subsequent implementation.

Conclusions
This research lays the groundwork for enhancing expert-recommended practices for colorectal lesion localization during colonoscopy in Winnipeg.We identified barriers and enablers from gastroenterologists and surgeons, mapping them to implementation science constructs.Despite some differences, both groups shared many perspectives, allowing us to create a unified list of implementation strategies to overcome barriers.We also compared participant-suggested strategies to those endorsed by implementation experts, forming a list of potentially effective local strategies.Future research should test these strategies' advantages and their impact on endoscopy quality.
*Excluding two surgeons who do not routinely perform colonoscopy as part of their clinical practice.**As an attending physician (excluding subspecialty training).
No policies to encourage recommended practices (Barrier) "I don't know what the incentive is for them to do it."(Gastroenterologist 12) "Maybe this comes from my background, but we should be monitoring how people are doing, and there should maybe be some sort of punishment if people aren't following the rules."(Surgeon 1) "I don't think there should be an incentive.If you say this is standard of care, you should follow it" (Gastroenterologist19) Vol:.(1234567890) Scientific Reports | (2024) 14:13157 | https://doi.org/10.1038/s41598-024-63753-xwww.nature.com/scientificreports/Unaware that repeat endoscopy occurs (Barrier) "I am very surprised, very surprised because, you know, I see the reports from the surgeons I refer to, and I don't recall, other than distal tumors, anyway, repeating the colonoscopy" (Gastroenterologist 6) "I'm not sure that I believe that all surgeons routinely repeat endoscopy or that surgeons frequently repeat endoscopy." (Surgeon 7) Organization doesn't understand endoscopy patient needs or prioritize QI (Barrier) "[The health authority] is a disaster when it comes to research.They don't understand that research drives good clinical care" (Gastroenterologist 8) "I would like to see an administrative structure where they value clinicians who want to do quality improvement and they facilitate it rather than just be blind to it or let these processes continue, like you pulling your hair out." (Surgeon 15) Individual participants had a good understanding of patient needs within their organization (Facilitator) "No one wants to go through any more colonoscopies than they absolutely have to.Everyone knows the ardour of drinking 4L of PegLyte, even if you haven't done it personally, it's not fun." (Gastroenterologist 2) "People have to have tests redone.And no big deal for us, but obviously a big deal for the person who has to take the prep and more so, you know, spend the next two weeks at home thinking, 'Oh my God, they didn't do something right in me.'" (Gastroenterologist 11) Cosmopolitanism Minimal networking related to endoscopy or colorectal cancer (Surgeons only; barrier) "Endoscopy and endoscopic markings?Bupkis.I don't network with anybody about this.I barely network with the people next door." (Surgeon 3) Strong connections with external institutions (Facilitator) "I usually attend one, pandemic notwithstanding, every year, actually, There's CDDW, and I would often participate in DDW as well." (Gastroenterologist 2) "Most of the people who I talk to still are in Toronto or Montreal or Edmonton, places where I know surgeons who I personally worked with, who work in those places." (Surgeon 7) "I don't know that we're necessarily going to be late adopters, but I don't know how many people make it their priority to be an early adopter either." (Gastroenterologist 18) "If somebody else has done it and proven it reduces the repeat scopes by 'X'-percentage, then that's a much easier sell.If not, it might be a little bit challenging" (Gastroenterologist 19) "Would it be valuable to us from the perspective of our reputation and admiration of our peers?I think the answer is probably not within the realm of surgery." (Surgeon 7) Valued being the first to adopt new recommendations.(Surgeons only; facilitator) "People would want to say, yeah, Winnipeg had the first people to do this because there's really there's no downside to it." (Surgeon 16) "It makes it look like we're staying on top of things" (Surgeon 14) Falling behind other organizations as a motivator to adopt the new recommendations (Gastroenterologists only; facilitator) "Winnipeg is behind the rest of the country." (Gastroenterologist 17) "Certainly, being on the forefront of making those types of changes is certainly a good thing and would only be looked at favourably." (Gastroenterologist 2) Continued Vol:.(1234567890)Scientific Reports | (2024) 14:13157 | https://doi.org/10.1038/s41598-024-63753-xwww.nature.com/scientificreports/ m here for the patient, so any patient that comes to contact me, including my colleagues, I'll stop for them and we'll take the time and we'll just have to suck it up as a medical institution.But the [health region] is basically saying, we can't" (Surgeon 20)

Table 3 .
CFIR barriers and facilitators to implementation of the new endoscopic lesion localization recommendations according to gastroenterologists and surgeons.COVID Coronavirus infectious disease 2019, CT computed tomography, NICE narrow band imaging international colorectal endoscopic, QI quality improvement.Italics signify a perception that was unique to one specialty group.Major barriers are signified in bold.

Table 4 .
Frequency of ERIC strategies suggested by interview participants compared to recommended strategies according to CFIR-ERIC strategy mapping.*Identified as a level 1 strategy to address barriers identified from CFIR-ERIC tool.† Identified as a strategy with one of the top 4 highest cumulative endorsement percentages in the CFIR-ERIC tool.